Smoking Cessation Intervention: An Evidence-Based Approach

Smoking is the leading cause of preventable death. Every year, more than 71600 of Poles and 36600 Romanians are killed by tobacco-caused disease. In whole European Union 1 400 000 people die due to tobacco smoking. Tobacco smoking causes many diseases like cardiovascular diseases, pulmonary diseases, cancer and others, however tobacco dependence is a disease itself. Tobacco dependence syndrome (F 17.2.- ICD X revision) is a chronic disease caused by nicotine dependence. The criteria to diagnose tobacco dependence are very similar to those recognized in drug and alcohol addiction. Tobacco dependence is a chronic condition that is treatable, however due to its nature often requires repeated intervention for success and good plan for treatment provided by specialist (doctor, nurse, health counsellor, therapist etc). The effective treatment exists and include pharmacotherapy and behavioural support. Both methods are effective itself but according to Cochrane library reviews the most effective is combing both medicines and psychological support. Evidence-based guidelines recommend nicotine replacement therapy, bupropion SR, and varenicline as effective in smoking cessation therapy, especially when combined with behavioral interventions. There is as well effective and safe herbal drug - cytisine, however not available in all European countries. The success rate is at least doubled by using evidence based methods in tobacco dependence treatment. The effects of alternative methods like hypnotherapy in smoking cessation in uncontrolled studies were not confirmed by analysis of randomized controlled trials. Electrostimulation is not effective for smoking cessation. Well‐designed research of acupuncture, acupressure and laser stimulation could be needed since these are very popular among smokers, though these interventions alone are likely to be less effective than evidence‐based interventions. There is an evidence from few trials that electronic cigarettes effectiveness in smoking cessation may be equal to nicotine patches or higher, when both products were accompanied by behavioral support.

Nicotine addiction is a chronic relapsing condition that can be difficult to treat. Until recently, pharmacological options for the treatment of tobacco dependence were primarily limited to nicotine replacement therapy (NRT). Sustained-release bupropion (bupropion SR) is the first non-nicotine pharmacological treatment approved for smoking cessation. Bupropion SR is recommended for first-line pharmacotherapy alongside NRT in the updated US Clinical Practice Guidelines and the UK Health Education Authority Guidelines. The UK National Institute of Clinical Excellence recommends NRT and bupropion SR for smokers who have expressed a desire to quit smoking. This review presents evidence that bupropion SR is an effective first-line therapy for smoking cessation in a wide range of patient populations. It is associated with significantly higher smoking cessation rates compared with placebo in patients with or without a history of prior bupropion SR or NRT use, and its effect is independent of gender. Bupropion SR treatment is effective in the prevention of relapse to smoking in those patients who have successfully quit, and re-treatment is effective in smokers who recommence smoking after a previous course of bupropion SR. Bupropion SR treatment relieves the symptoms of craving and nicotine withdrawal, and attenuates the weight gain that often occurs after smoking cessation. Data collected from motivational support programmes and employer-based studies provide strong evidence of the effectiveness of bupropion SR as an aid to smoking cessation in 'real life' situations, and confirm the efficacy seen in clinical trials.

The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes. The aims of this review were to determine the effectiveness of the different forms of nicotine replacement therapy (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; and to determine its effectiveness compared to other pharmacotherapies. We searched the Cochrane Tobacco Addiction Group trials register in April 2001. Randomized trials in which NRT was compared to placebo or no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow-up of less than six months. We extracted data in duplicate on the type of subjects, the dose and duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measures was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed effects model (Peto). We identified 108 trials; 94 with a non NRT control group. The odds ratio for abstinence with NRT compared to control was 1.73 (95% confidence interval 1.62-1.85), The odds ratios for the different forms of NRT were 1.66 for gum, 1.76 for patches, 2.27 for nasal spray, 2.08 for inhaled nicotine and 1.73 for nicotine sublingual tablet. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2mg gum (odds ratio 2.67, 95% confidence interval 1.69 to 4.22). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy, in which bupropion was significantly more effective than nicotine patch or placebo. All of the commercially available forms of NRT (nicotine gum, transdermal patch, the nicotine nasal spray, nicotine inhaler and nicotine sublingual tablets) are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. There is promising evidence that bupropion may be more effective than NRT (either alone or in combination). However, its most appropriate place in the therapeutic armamentarium requires further study and consideration.

Background: Many studies have shown that smoking cessation is cost-effective; however, there have been no pharmacoeconomic trials directly comparing nicotine replacement therapy (NRT) with bupropion SR, the current mainstays of pharmacologic therapy for nicotine dependence. Objective: To evaluate and compare clinical efficacy and cost-effectiveness of either NRT or once-daily bupropion SR using patient-reported continuous six-month quit rates and pharmacoeconomic evaluation. Methods: Retrospective data on six-month abstinence rates were obtained on 287 Veterans Affairs people who enrolled in our smoking cessation programs from August 1997 to May 1998. These subjects received either NRT patches or once-daily bupropion SR along with counseling on behavioral modification. Quit rates were calculated to compare the efficacy of NRT versus once-daily bupropion SR. Pharmacoeconomic cost analysis data were calculated to determine actual and guideline cost of each medication group. The costs of success and failure of both NRT patches and bupropion SR were also determined. Results: Six-month quit rates were not significantly different in NRT patches versus bupropion SR groups (27.7% vs. 31%; p > 0.702). Pharmacoeconomic analysis revealed that overall cost of therapy was $158 for medication/patient receiving NRT versus $67/patient taking bupropion SR. Actual cost of success for NRT was $140/patient compared with $199/patient if doses matched guideline recommendations. Actual cost of failure for NRT was $166/patient compared with $138/patient if guideline doses were used. Patients who successfully quit smoking with NRT used pharmacologic treatment for approximately three weeks less than the guideline time period; patients who failed with NRT used therapy about 10 days longer than the guideline time. Actual cost of success for bupropion SR was $74/patient compared with $42/patient if guideline doses were used. Cost of failure with bupropion SR was $63/patient compared with $32/patient if guidelines were followed. Patients successful with bupropion SR used the treatment six weeks longer than our guideline, while patients who failed on bupropion SR used the therapy eight weeks beyond the guideline. Conclusions: NRT and bupropion SR were equally efficacious; however, bupropion SR was more cost-effective than NRT. Increasing the duration of therapy with NRT beyond our guideline period increased the cost of failure.

Ten Million Calls and Counting: Progress and Promise of Tobacco Quitlines in the U.S.

E-cigarettes for tobacco cessation: Not the solution.

Nurse-Conducted Smoking Cessation in Patients With COPD Using Nicotine Sublingual Tablets and Behavioral Support

Tobacco smoking is a major modifiable risk for poor pregnancy outcomes. Pregnant women whose partner smokes are six times more likely to continue smoking. Typically, interventions target pregnant mothers or smoking fathers to reduce second-hand smoke exposure. Evidence reviews advocate for couple-targeted smoking cessation interventions, however no recent review has evaluated the effectiveness of interventions targeting both pregnant women and their partner/household member. We aimed to systematically review and evaluate the effectiveness of smoking cessation interventions targeting the couple/household where both parties smoke for antenatal smoking cessation in pregnant women. We searched 8 databases (MEDLINE, Embase, Emcare, AMED, BNI, CINAHL, PsycINFO, Cochrane Register of Controlled Trials) for randomised controlled trials (RCTs), controlled non-randomised studies and before-and-after studies, meeting PICO criteria: Population: pregnant woman and her partner/household member/s who are tobacco smokers antenatally. Tobacco smoking cessation intervention targeting a couple/household. Intervention targeting woman only, usual care, historical control group. Outcome/s: Objectively assessed or self-reported antenatal maternal smoking cessation. Studies were systematically selected for inclusion and data were extracted by two researchers. Meta-analysis was not undertaken due to clinical and methodological heterogeneity, including differing intervention types, outcome measures, cut-offs used to define cessation and follow-up timepoints. Data were narratively synthesised. Six studies were included: 4 RCTs, 1 non-randomised comparative study and 1 before-and-after study. Interventions were poorly described, variable in content across studies, and differed in content between women and partners/household members within studies. They included behavioural support (n = 6 women, n = 4 partners), written or self-help materials (n = 4 women, n = 6 partners), nicotine replacement therapy (n = 1 women, n = 1 partners), demonstration of smoking effects on the fetal heart (n = 1 women) and incentives (n = 1 women). Three studies directly targeted partners and three targeted them indirectly via the woman. Only one study compared targeting the couple versus the woman only. Varied subjective and objective cessation measures were assessed. Quit definition, measurement timepoint, and whether partner cessation was evaluated varied. Two RCTs, one non-randomised controlled and one before-and-after study reported that their intervention positively impacted smoking cessation for women compared with usual care. One RCT reported increased cessation for intervention versus control for partners. Few up-to-date studies have evaluated smoking cessation interventions targeting couples/households who smoke during pregnancy. Interventions rarely directly target partners. Interventions directly targeting the woman and her partner or smoking household members, using up-to-date interventions (e.g., nicotine replacement therapy, vapes, behavioural support) are yet to be assessed in high quality studies and more evidence in this field is needed. Standardised outcomes for both women and partners are needed to evaluate efficacy, identify the active components of interventions and facilitate evidence syntheses.

Feasibility and Pilot Efficacy of a Brief Smoking Cessation Intervention Delivered by Vascular Surgeons: The Vascular Physician Offer and Report (VAPOR) Trial

Cancer Risk Factors Among Adults with Serious Mental Illness

Is nicotine replacement really ineffective? A reply to Stanley and Massey

The mainstay in smoking cessation is counselling in combination with varenicline, nicotine replacement therapy (NRT) or bupropion SR. Varenicline and combination of two NRTs is equally effective, while varenicline alone is more effective than either NRT or bupropion SR. NRT is extremely safe but cardiovascular and psychiatric adverse events with varenicline have been reported. These treatments have also been shown to be effective in patients with chronic obstructive pulmonary disease (COPD). A model study is the Lung Health Study from the USA. Findings from this study of 5,587 patients with mild COPD showed that repeated smoking cessation for a period of 5 yrs resulted in a quit rate of 37%. After 14.5 yrs the quitters had a higher lung function and a higher survival rate. A study with a new nicotine formulation, a mouth spray, showed high relative efficacy. As 5-10% of quitters use long-term NRT, we report the results of a study where varenicline compared with placebo increased the quit rate in long-term users of NRT. Smoking cessation is the most effective intervention in stopping the progression of COPD, as well as increasing survival and reducing morbidity. This is why smoking cessation should be the top priority in the treatment of COPD.

Reply

Tobacco smoking is widespread and is one of the world’s most prevalent modifiable risk factors for morbidity and mortality. It is important to facilitate smoking cessation better in order to reduce the health consequences of tobacco use. The most effective approach assisting smokers in their quit attempts combines both pharmacotherapy and nonpharmacological interventions. This review summarizes the latest international epidemiological data available on tobacco use, considers the associated effects on health, and reviews existing policies against tobacco use. Among the interventions for smoking cessation, the three major pharmacotherapies (which have demonstrated efficacy when combined with behavioral support) are discussed: nicotine replacement therapy (NRT), bupropion, and varenicline. As the newest pharmacotherapy made available in this area, particular consideration is given to varenicline, and a review of our clinical experience is offered.

Few studies have compared cost-effectiveness of different smoking cessation interventions (SCIs) that include behavioral support, considering smoking-related diseases. Therefore, we compare the cost-effectiveness of SCIs with behavioral support in South Korea using the Benefits of Smoking Cessation on Outcomes (BENESCO) model. We used the BENESCO model to estimate the cost and utility of the SCIs with behavioral support, including pharmacist counseling with nicotine replacement therapy (pharmacist+NRT), expert counseling with NRT (expert+NRT), and expert counseling with varenicline (expert+varenicline). The target population was adult smokers who wanted to cease smoking within 1 month. We applied transitional probabilities and epidemiological data from the literature. Medical costs and utilities were calculated using claims and national survey data, respectively. Cost-effectiveness was evaluated within the threshold (17 926 USD per quality-adjusted life years [QALYs]) by incremental cost-effectiveness ratio (ICER). The model cohort included 1 219 390 male and 298 511 female smokers. The pharmacist+NRT group had 32 842 more QALYs gained and 26 689 958 USD less expended than the expert+NRT group. The ICER for the expert+varenicline group versus the pharmacist+NRT and expert+NRT groups was 27 247 and 4074 USD per QALY, respectively. The robustness of the results was confirmed by sensitivity analyses, except for the discount rate and cost of the expert+varenicline group. In Korea, pharmacist counseling with NRT showed higher QALY gains and lower costs than expert counseling with NRT. Expert counseling with varenicline was more effective for smoking cessation and more cost-effective than expert counseling with NRT but was not cost-effective compared with pharmacist counseling with NRT. This study provides evidence for decision-making on smoking cessation programs by evaluating the cost-effectiveness of SCIs. Furthermore, we attempted to use the BENESCO model to compare and evaluate the cost-effectiveness of SCIs with behavioral support. It is meaningful because this study showed the availability of using the BENESCO model in the future cost-effectiveness analysis of various SCIs.